Florida 2022 Regular Session

Florida House Bill H0805 Compare Versions

Only one version of the bill is available at this time.

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3	3	HB 805 2022
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7	7	CODING: Words stricken are deletions; words underlined are additions.
8	8	hb0805-00
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10	10	F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
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14	14	A bill to be entitled 1
15	15	An act relating to overpayment claims by health 2
16	16	insurers; amending s. 627.6131, F.S.; revising the 3
17	17	timeframe for overpayment claims by health insurers 4
18	18	against providers; providing applicability of such 5
19	19	timeframe to overpayment claims as a result of 6
20	20	specified retroactive review or audit; creating s. 7
21	21	627.65725, F.S.; providing requirements for 8
22	22	overpayment claims that are sent to providers by 9
23	23	insurers issuing group, blanket, and franchise health 10
24	24	insurance policies; providing timeframes for 11
25	25	submissions of overp ayment claims; providing 12
26	26	applicability of specified timeframes; providing 13
27	27	timeframes and procedures for paying, denying, and 14
28	28	contesting overpayment claims and for submitting 15
29	29	certain information; prohibiting insurers from 16
30	30	reducing certain payments to provid ers; providing 17
31	31	exceptions; providing the date of payment of 18
32	32	overpayment claims; providing interest rates and 19
33	33	interest accrual start dates; amending s. 641.3155, 20
34	34	F.S.; revising the timeframes for overpayment claims 21
35	35	by health maintenance organizations agains t providers; 22
36	36	providing applicability of such timeframe to 23
37	37	overpayment claims as a result of specified 24
38	38	retroactive review or audit; providing an effective 25
39	39
40	40	HB 805 2022
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44	44	CODING: Words stricken are deletions; words underlined are additions.
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47	47	F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
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49	49
50	50
51	51	date. 26
52	52	27
53	53	Be It Enacted by the Legislature of the State of Florida: 28
54	54	29
55	55	Section 1. Subsection (19) o f section 627.6131, Florida 30
56	56	Statutes, is renumbered as subsection (18), and subsection (6) 31
57	57	and present subsection (18) of that section are amended to read: 32
58	58	627.6131 Payment of claims. — 33
59	59	(6) If a health insurer determines that it has made an 34
60	60	overpayment to a provider for services rendered to an insured, 35
61	61	the health insurer must make a claim for such overpayment to the 36
62	62	provider's designated location. A health insurer that makes a 37
63	63	claim for overpayment to a provider under this section shall 38
64	64	give the provider a written or electronic statement specifying 39
65	65	the basis for the retroactive denial or payment adjustment. The 40
66	66	insurer must identify the claim or claims, or overpayment claim 41
67	67	portion thereof, for which a claim for overpayment is submitted. 42
68	68	(a)1. Except as provided in subparagraph 2., a claim for 43
69	69	overpayment must be submitted to a provider within 12 months 44
70	70	after the health insurer's payment of the claim. The 12 -month 45
71	71	timeframe applies to claims that include, but are not limited 46
72	72	to: 47
73	73	a. Any claim for overpa yment as a result of a retroactive 48
74	74	review or audit of coverage decisions or payment levels not 49
75	75	related to fraud, as described in paragraph (b); or 50
76	76
77	77	HB 805 2022
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79	79
80	80
81	81	CODING: Words stricken are deletions; words underlined are additions.
82	82	hb0805-00
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84	84	F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
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86	86
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88	88	b. Any claim for overpayment submitted to a provider 51
89	89	licensed under chapter 458, chapter 459, chapter 460, chapter 52
90	90	461, or chapter 466. 53
91	91	2.(b) A claim for overpayment shall not be permitted 54
92	92	beyond 30 months after the health insurer's payment of a claim, 55
93	93	except that claims for overpayment may be sought beyond 12 56
94	94	months after the health insurer's payment of the claim to a 57
95	95	provider that time from providers convicted of fraud pursuant to 58
96	96	s. 817.234. 59
97	97	(b)(a) If an overpayment determination is the result of 60
98	98	retroactive review or audit of coverage decisions or payment 61
99	99	levels not related to fraud, a provider and a health insurer 62
100	100	shall adhere to the following procedures: 63
101	101	1. The All claims for overpayment must be submitted to a 64
102	102	provider within 30 months after the health insurer's payment of 65
103	103	the claim. A provider must pay, deny, or contest the health 66
104	104	insurer's claim for overpayment within 40 days after the receipt 67
105	105	of the claim. All contested claims for overpayment must be paid 68
106	106	or denied within 120 days after receipt of the claim. Failure to 69
107	107	pay or deny overpayment and claim within 140 days after receipt 70
108	108	creates an uncontestable obligation to pay the claim. 71
109	109	2. A provider that denies or contests a health insurer's 72
110	110	claim for overpayment or any portion of a claim shall notify the 73
111	111	health insurer, in writing, within 35 days after the provider 74
112	112	receives the claim that the claim for overpayment is contested 75
113	113
114	114	HB 805 2022
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118	118	CODING: Words stricken are deletions; words underlined are additions.
119	119	hb0805-00
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121	121	F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
122	122
123	123
124	124
125	125	or denied. The notice that the claim for overpayment is denied 76
126	126	or contested must identify the contested portion of the claim 77
127	127	and the specific reason for contesting or denying the claim and, 78
128	128	if contested, must include a request for additional information. 79
129	129	If the health insurer submits additional information, the health 80
130	130	insurer must, within 35 days after receipt of the request, mail 81
131	131	or electronically transfer the information to the provider. The 82
132	132	provider shall pay or deny the cla im for overpayment within 45 83
133	133	days after receipt of the information. The notice is considered 84
134	134	made on the date the notice is mailed or electronically 85
135	135	transferred by the provider. 86
136	136	3. The health insurer may not reduce payment to the 87
137	137	provider for other servi ces unless the provider agrees to the 88
138	138	reduction in writing or fails to respond to the health insurer's 89
139	139	overpayment claim as required by this paragraph. 90
140	140	4. Payment of an overpayment claim is considered made on 91
141	141	the date the payment was mailed or electronic ally transferred. 92
142	142	An overdue payment of a claim bears simple interest at the rate 93
143	143	of 12 percent per year. Interest on an overdue payment for a 94
144	144	claim for an overpayment begins to accrue when the claim should 95
145	145	have been paid, denied, or contested. 96
146	146	(18) Notwithstanding the 30 -month period provided in 97
147	147	subsection (6), all claims for overpayment submitted to a 98
148	148	provider licensed under chapter 458, chapter 459, chapter 460, 99
149	149	chapter 461, or chapter 466 must be submitted to the provider 100
150	150
151	151	HB 805 2022
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155	155	CODING: Words stricken are deletions; words underlined are additions.
156	156	hb0805-00
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158	158	F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
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160	160
161	161
162	162	within 12 months after the health insurer's payment of the 101
163	163	claim. A claim for overpayment may not be permitted beyond 12 102
164	164	months after the health insurer's payment of a claim, except 103
165	165	that claims for overpayment may be sought beyond that time from 104
166	166	providers convicted of fraud pursuant to s. 817.234. 105
167	167	Section 2. Section 627.65725, Florida Statutes, is created 106
168	168	to read: 107
169	169	627.65725 Overpayment claims. —If an insurer issuing a 108
170	170	group, blanket, or franchise health insurance policy determines 109
171	171	that it has made an overpayment to a pro vider for services 110
172	172	rendered to an insured, the insurer must make a claim for such 111
173	173	overpayment to the provider's designated location. An insurer 112
174	174	issuing a group, blanket, or franchise health policy that makes 113
175	175	a claim for overpayment to a provider shall give the provider a 114
176	176	written or electronic statement specifying the basis for the 115
177	177	retroactive denial or payment adjustment. The insurer must 116
178	178	identify the claim or claims, or overpayment claim portion 117
179	179	thereof, for which a claim for overpayment is submitted. 118
180	180	(1)(a) Except as provided in paragraph (b), a claim for 119
181	181	overpayment must be submitted to a provider within 12 months 120
182	182	after the insurer's payment of the claim. The 12 -month timeframe 121
183	183	applies to claims that include, but are not limited to: 122
184	184	1. Any claim for overpayment as a result of a retroactive 123
185	185	review or audit of coverage decisions or payment levels not 124
186	186	related to fraud, as described in subsection (2); or 125
187	187
188	188	HB 805 2022
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190	190
191	191
192	192	CODING: Words stricken are deletions; words underlined are additions.
193	193	hb0805-00
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195	195	F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
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197	197
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199	199	2. Any claim for overpayment submitted to a provider 126
200	200	licensed under chapter 458, chapter 459, chapter 460, chapter 127
201	201	461, or chapter 466. 128
202	202	(b) A claim for overpayment may be sought beyond 12 months 129
203	203	after the insurer's payment of the claim to a provider convicted 130
204	204	of fraud pursuant to s. 817.234. 131
205	205	(2) If an overpayment determination is the result of 132
206	206	retroactive review or audit of coverage decisions or payment 133
207	207	levels not related to fraud, a provider and the insurer shall 134
208	208	adhere to the following procedures: 135
209	209	(a) The provider must pay, deny, or contest the insurer's 136
210	210	claim for overpayment within 40 days after r eceipt of the claim. 137
211	211	All contested claims for overpayment must be paid or denied 138
212	212	within 120 days after receipt of the claim. Failure to pay or 139
213	213	deny overpayment and claim within 140 days after receipt creates 140
214	214	an uncontestable obligation to pay the claim. 141
215	215	(b) A provider that denies or contests the insurer's claim 142
216	216	for overpayment or any portion of a claim shall notify the 143
217	217	insurer, in writing, within 35 days after the provider receives 144
218	218	the claim that the claim for overpayment is contested or denied. 145
219	219	The notice that the claim for overpayment is denied or contested 146
220	220	must identify the contested portion of the claim and the 147
221	221	specific reason for contesting or denying the claim and, if 148
222	222	contested, must include a request for additional information. If 149
223	223	the insurer submits additional information, the insurer must, 150
224	224
225	225	HB 805 2022
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228	228
229	229	CODING: Words stricken are deletions; words underlined are additions.
230	230	hb0805-00
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232	232	F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
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234	234
235	235
236	236	within 35 days after receipt of the request, mail or 151
237	237	electronically transfer the information to the provider. The 152
238	238	provider shall pay or deny the claim for overpayment within 45 153
239	239	days after receipt of the informati on. The notice is considered 154
240	240	made on the date the notice is mailed or electronically 155
241	241	transferred by the provider. 156
242	242	(c) The insurer may not reduce payment to the provider for 157
243	243	other services unless the provider agrees to the reduction in 158
244	244	writing or fails to respond to the insurer's overpayment claim 159
245	245	as required by this subsection. 160
246	246	(d) Payment of an overpayment claim is considered made on 161
247	247	the date the payment was mailed or electronically transferred. 162
248	248	An overdue payment of a claim bears simple interest at th e rate 163
249	249	of 12 percent per year. Interest on an overdue payment for a 164
250	250	claim for an overpayment begins to accrue when the claim should 165
251	251	have been paid, denied, or contested. 166
252	252	Section 3. Subsection (17) of section 641.3155, Florida 167
253	253	Statutes, is renumbered as subsection (16), and subsection (5) 168
254	254	and present subsection (16) of that section are amended to read: 169
255	255	641.3155 Prompt payment of claims. — 170
256	256	(5) If a health maintenance organization determines that 171
257	257	it has made an overpayment to a provider for services ren dered 172
258	258	to a subscriber, the health maintenance organization must make a 173
259	259	claim for such overpayment to the provider's designated 174
260	260	location. A health maintenance organization that makes a claim 175
261	261
262	262	HB 805 2022
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266	266	CODING: Words stricken are deletions; words underlined are additions.
267	267	hb0805-00
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269	269	F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
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271	271
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273	273	for overpayment to a provider under this section shall give the 176
274	274	provider a written or electronic statement specifying the basis 177
275	275	for the retroactive denial or payment adjustment. The health 178
276	276	maintenance organization must identify the claim or claims, or 179
277	277	overpayment claim portion thereof, for which a claim for 180
278	278	overpayment is submitted. 181
279	279	(a)1. Except as provided in subparagraph 2., a claim for 182
280	280	overpayment must be submitted to a provider within 12 months 183
281	281	after the health maintenance organization's payment of the 184
282	282	claim. The 12-month timeframe applies to claims that include, 185
283	283	but are not limited to: 186
284	284	a. Any claim for overpayment as a result of a retroactive 187
285	285	review or audit of coverage decisions or payment levels not 188
286	286	related to fraud, as described in paragraph (b); or 189
287	287	b. Any claim for overpayment submitted to a provider 190
288	288	licensed under chapter 458, chapter 459, chapter 460, chapter 191
289	289	461, or chapter 466. 192
290	290	2.(b) A claim for overpayment shall not be permitted 193
291	291	beyond 30 months after the health maintenance organization's 194
292	292	payment of a claim, except that claims for overpayment may be 195
293	293	sought beyond 12 months after the health maintenance 196
294	294	organization's payment of the claim to a provider that time from 197
295	295	providers convicted of fraud pursuant to s. 817.234. 198
296	296	(b)(a) If an overpayment determination is the result of 199
297	297	retroactive review or audit o f coverage decisions or payment 200
298	298
299	299	HB 805 2022
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303	303	CODING: Words stricken are deletions; words underlined are additions.
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306	306	F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
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310	310	levels not related to fraud, a provider and a health maintenance 201
311	311	organization shall adhere to the following procedures: 202
312	312	1. The All claims for overpayment must be submitted to a 203
313	313	provider within 30 months after the health ma intenance 204
314	314	organization's payment of the claim. A provider must pay, deny, 205
315	315	or contest the health maintenance organization's claim for 206
316	316	overpayment within 40 days after the receipt of the claim. All 207
317	317	contested claims for overpayment must be paid or denied with in 208
318	318	120 days after receipt of the claim. Failure to pay or deny 209
319	319	overpayment and claim within 140 days after receipt creates an 210
320	320	uncontestable obligation to pay the claim. 211
321	321	2. A provider that denies or contests a health maintenance 212
322	322	organization's claim for o verpayment or any portion of a claim 213
323	323	shall notify the organization, in writing, within 35 days after 214
324	324	the provider receives the claim that the claim for overpayment 215
325	325	is contested or denied. The notice that the claim for 216
326	326	overpayment is denied or contested mus t identify the contested 217
327	327	portion of the claim and the specific reason for contesting or 218
328	328	denying the claim and, if contested, must include a request for 219
329	329	additional information. If the organization submits additional 220
330	330	information, the organization must, withi n 35 days after receipt 221
331	331	of the request, mail or electronically transfer the information 222
332	332	to the provider. The provider shall pay or deny the claim for 223
333	333	overpayment within 45 days after receipt of the information. The 224
334	334	notice is considered made on the date the notice is mailed or 225
335	335
336	336	HB 805 2022
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340	340	CODING: Words stricken are deletions; words underlined are additions.
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343	343	F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
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345	345
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347	347	electronically transferred by the provider. 226
348	348	3. The health maintenance organization may not reduce 227
349	349	payment to the provider for other services unless the provider 228
350	350	agrees to the reduction in writing or fails to respond to the 229
351	351	health maintenance organization's overpayment claim as required 230
352	352	by this paragraph. 231
353	353	4. Payment of an overpayment claim is considered made on 232
354	354	the date the payment was mailed or electronically transferred. 233
355	355	An overdue payment of a claim bears simple interest at the ra te 234
356	356	of 12 percent per year. Interest on an overdue payment for a 235
357	357	claim for an overpayment payment begins to accrue when the claim 236
358	358	should have been paid, denied, or contested. 237
359	359	(16) Notwithstanding the 30 -month period provided in 238
360	360	subsection (5), all claims for overpayment submitted to a 239
361	361	provider licensed under chapter 458, chapter 459, chapter 460, 240
362	362	chapter 461, or chapter 466 must be submitted to the provider 241
363	363	within 12 months after the health maintenance organization's 242
364	364	payment of the claim. A claim for overp ayment may not be 243
365	365	permitted beyond 12 months after the health maintenance 244
366	366	organization's payment of a claim, except that claims for 245
367	367	overpayment may be sought beyond that time from providers 246
368	368	convicted of fraud pursuant to s. 817.234. 247
369	369	Section 4. This act shall take effect July 1, 2022. 248